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d . ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 9J 1601 E.E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f – (Complete in Triplicate) q P P Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f / / Job Address" r City S_ Lot Size PM Owner's Name _ _� 011 Ad ess O �7j a,�`� ', Phone Contractor �eL. Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE LINES POSAL FLD. PROP. LINE FOUNDATION AGRICUL AE WELL OTHER WELL PITS/SUMPS r. . INTENDED USE TYPE OF WELL PROBLEM AREA CO T TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca o ell Excavation Dia:of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca - g Specifications ("1 Public 1-1 Other Cl Delt Depth of Grou eat Type of Grout _ I 1 Irrigation _Approx. Depth astern Surface Seal'lnsta by Repair Work Done ❑ Type of Pump _ H.P. _ State Work Done_ Well Destruction . ❑ Well Diameter'. Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [.'I REPAIR/ADDITION I I DESTRUCTIOPPIKYNo septic system permitted if public sewer is `f available within 200 feet.) Installation will serve: Residence'e Commercial_ Other. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: — Water table depth G SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines Notal length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i'I Depth Size Number �{�] SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 0 certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applica ust call for all reguirod inspections. Complete drawing on reverse side. Signed X �'�'� / Title: Date: �Lx1 CN U'Q<_1J,. FOR DEPARTMENT USE ONLY Application Accepted by _ bate Area v Pit or Grout Inspection by 7��Dte� Final Inspection by Date 3 O Additional Comments: S f E ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 SJ INFO FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PEHMIT'NO.r EH 13-24(REV.I�M51 O h lk� ]CI EH 14.28 L/ '�